Medical therapy. Management of the refractory patient.

Although relatively rare, GERD patients refractory to medical therapy remain a challenge for the clinician. Refractoriness can be diagnosed only if the patient is properly studied on medication and if what should be adequate medical therapy has been given a sufficient therapeutic trial. Use of 24-hour intragastric and intraesophageal pH-metry has improved the ability to manage patients who appear to be nonresponders. Simple advice and minor adjustments to medical therapy are usually all that is needed for most patients, but in some, management requires knowledge of the principles outlined in this article. If followed, only a small group of patients should be medically refractory.